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Division of Medical Assistance |
| Medicaid for North Carolinians |
Health Choice for Children | Medicaid Providers | County Staff | DMA Publications |
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Reporting a Change in Provider Status
Providers are responsible for notifying Medicaid when information related to their business or practice changes. How a change is reported to Medicaid depends on the type of change that is being reported.
- All forms must be signed by the individual provider or, for a group, the authorized agent.
- Changes submitted using the Medicaid Provider Change Form may be submitted by mail or fax.
- Changes that require the submittal of a new Provider Enrollment Packet, Enrollment Addendum, or new Provider Participation Agreement must be submitted by mail because an original signature is required.
Type of Change |
How to Report the Change |
|
|---|---|---|
| 1 | For changes to your Carolina ACCESS practice (change in contact person's name, after-hours telephon number, restriction information, enrollment limits, counties served) |
Submit the Medicaid Provider Change Form |
| 2 | For changes to your National Provider Number |
Submit the Medicaid Provider Change Form with a copy the NPPES Letter attached to the form. |
| 3 | For CLIA recertification | Submit the Medicaid Provider Change Form with a copy of your new certificate attached to the form. |
| 4 | For voluntary participation termination | Submit the Medicaid Provider Change Form with a notification letter on your letterhead attached to the form. |
| 5 | For bed capacity changes | Submit the Medicaid Provider Change Form with a copy your new license attached to the form. |
| 6 | For changes to your billing contact information or site (physicial location) contact information (telephone number, fax number, e-mail) | Submit the Medicaid Provider Change Form |
| 7 | For changes to your billing address | Submit the Medicaid Provider Change Form |
| 8 | For changes to your site (physical location) address | Submit
Note: Must be submitted by mail. |
| 9 | To add a site | Submit a new Provider Enrollment Packet |
| 10 | To add or delete an individual to your group | Submit the Medicaid Provider Change Form |
| 11 | For group name/tax name changes |
Submit a new Provider Enrollment Packet |
| 12 | For individual name/tax name changes | Submit
|
| 13 | For tax number changes | Submit a new Provider Enrollment Packet |
| 14 | For a change in ownership | Submit a new Provider Enrollment Packet |
| 15 | For Residential Child Care Treatment Facility treatment level changes | Submit the Medicaid Provider Change Form with a copy your new license and Letter of Endorsement attached to the form. |
| 16 | Federally Qualified Health Center Providers To add a new service to the services you are currently enrolled to provide |
Submit a new Provider Enrollment Packet |
| 17 | Community Alternatives Program Providers To add a new service to the services you are currently enrolled to provide |
Submit the CAP Addendum to Add Services |
| 18 | Community Intervention Service Providers To add a new service to the services you are currently enrolled to provide |
Submit the Provider Enrollment Packet |
Additional Documentation Required for a Site Address Change
Provider Type |
Required Documentation |
|---|---|
Adult Care Homes |
New License |
Ambulance Services |
New License |
Ambulatory Surgery Centers |
New CMS Approval Letter |
At Risk Case Management |
New Certification |
Birthing Centers |
New Certification |
Certified Registered Nurse Anesthetists, Individuals |
New License |
Community Alternatives Programs (CAP/C, CAP/DA, CAP/Choice) |
Applicable Accreditation/Licensure |
Community Alternatives Programs (CAP/MR-DD) |
Applicable Accreditation/Licensure/Endorsement |
Community Intervention Services |
Applicable Accreditation/Licensure/Endorsement |
Dental Providers, Individuals |
New License |
Dialysis Centers |
New CMS Approval Letter |
Durable Medical Equipment |
New Permit |
Federally Qualified Health Centers |
New CMS Approval Letter |
Free-standing Independent Laboratories |
New Certification |
Hearing Aid Providers |
New License |
HIV Case Management |
New Certification |
Home Infusion Therapy Providers |
New License |
Home Health Services |
New License |
Hospice Services |
New License |
Hospitals |
New CMS Approval Letter |
Hospitals, Critical Access |
New CMS Approval Letter |
ICF/MR Providers |
New License |
Independent Diagnostic Testing Facility |
New CMS Approval Letter |
Independent Practitioners, Individuals |
New Certification |
Maternity Care Coordination Services |
New Certification |
Nurse Midwives, Individual |
New License |
Nurse Practitioner (non-mental health), Individuals |
New License |
Nursing Facility Services |
New CMS Approval Letter |
Orthotics and Prosthetics Providers |
New Certification |
Outpatient Mental Health Providers, Individuals |
Applicable Accreditation/Licensure/Endorsement |
Personal Care Services |
New License |
Pharmacies |
New Permit |
Physicians, Individuals |
New License |
Portable X-ray Services |
New License |
Private Duty Nursing |
New License |
Psychiatric Hospitals |
New License |
Psychiatric Residential Treatment Facilities |
New License |
Residential Child Care Facilities |
New License |
Rural Health Clinics |
New CMS Approval Letter |
Additional Documenation Required for Individuals Reporting a Name Change
Provider Type |
Required Documentation |
|---|---|
Certified Registered Nurse Anesthetists |
New License New Certification New CMS Approval Letter |
Dentists |
New License |
Independent Practitioners |
New Certification |
Nurse Midwives |
New License New Certification |
Nurse Practitioners |
New License New Certification |
Orthotics and Prosthetics Providers |
New Certification |
Outpatient Mental Health Providers |
Applicable Accreditation/Licensure |
Physicians |
New License |
Updated November 7, 2008